Provider Demographics
NPI:1871819870
Name:WELLNESS WORX CENTER PLLC
Entity Type:Organization
Organization Name:WELLNESS WORX CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:PETTERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:727-474-9729
Mailing Address - Street 1:2495 ENTERPRISE RD
Mailing Address - Street 2:STE104
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33763-1795
Mailing Address - Country:US
Mailing Address - Phone:727-474-9729
Mailing Address - Fax:727-474-9947
Practice Address - Street 1:2495 ENTERPRISE RD
Practice Address - Street 2:STE104
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33763-1795
Practice Address - Country:US
Practice Address - Phone:727-474-9729
Practice Address - Fax:727-474-9947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8923111N00000X
FLCH8772111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9067913OtherCIGNA
FL1038157OtherAMERICAN SPECIALTY HEALTH
FL1147626OtherFIRST HEALTH
FL1538210OtherAETNA
FL71494OtherBLUE CROSS BLUE SHIELD OF FL
FL656080OtherUNITED HEALTH CARE